Irvine Jr, John NEW YORK STATE DEPARTMENT OF HEALTH t- ' # 10
Vital Records Section Burial - Transit Permit
r Name First
John Date of Death
Middle Last Sex
Steven Irvine,Jr. Male
Age If Veteran of U.S. Armed Forces,
February 13,2016
187 War or Dates Korean
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 37 Marcy Lane
Manner of Death X Natural Cause I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
William Borgos,MD
'{f Address
9 Carey Road
Deat et i ate File Di act Number Re aster Number
City, own o VillageQ .4-NSb1/4n._.--• ( f
❑Burial Date Cemetery or Crematory
❑Entombment February 16, 2016 Pine View Crematorium
Address
❑
x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
' Removal and/or Held
and/or Address
1 Hold
N
O Date Point of
O. Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
p. Address
r1 407 Bay Road, Queensbury, NY 12804
1/ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described a ve as indicated.
rr CTs
Date Issued -I 1 Ca 1 1 to Registrar of Vital Statistics . n....i.._
r (signature)
f/ District Numbers(y S m Place ) G �� c -c �Q�
I certify that the remainsof the decedent identified above were disposed of in accord with this permit on:
W /
Date of Disposition Z!lg/l. Place of Disposition ntuud erwncda(10../
W (address)
U)
tY (section) j (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises lhnstlease
,Sr,►,r144-
.Z print)
Signature4 Title (i triA
(over)
DOH-1555(02/2004)